Have you been told your testosterone is the problem?
Almost every woman with PMOS (formerly PCOS, polycystic ovary syndrome) hears it, so treatments get scored on lowering testosterone. A 2023 analysis ranking the drugs for it judged them only on the change in testosterone.
In 1990, researchers switched off the ovaries of nine women with PCOS, holding their testosterone in the normal range for about ten weeks. Their insulin resistance barely moved. A year later, a second team held insulin back instead, and in ten days the protein that parks testosterone rose by about a third and free testosterone fell by more than 40%. Testosterone is the bystander. Insulin does the damage.
The new name, and what the old one missed
In 2026, a global consensus in The Lancet renamed it polyendocrine metabolic ovarian syndrome, and the new name adds the word metabolic. The "cysts" were always stalled follicles. An adult needs two of three: irregular or missing ovulation, signs of too much androgen (acne, unwanted hair, scalp thinning or a high blood level), and polycystic-looking ovaries or a high AMH. A teenager needs the first two, no ultrasound. No cysts doesn't mean no PMOS.
PMOS is insulin resistance
I have yet to find a woman with PMOS who isn't insulin resistant, and a 2021 review cowritten by two of the international guideline's own authors calls insulin resistance a near-uniform finding. Insulin turns up ovarian androgen production and turns down SHBG, sex hormone binding globulin, the liver's parking garage that holds testosterone so it can't act. A smaller garage leaves more testosterone free. In a 2003 study, women with high insulin had the same total testosterone as those with normal insulin, less than half the SHBG and twice the free testosterone index.
In a 2013 study using the clamp, the gold standard test, three in four lean women with PMOS were insulin resistant, with a fasting insulin score identical to healthy lean women's.
What it costs her
Insulin resistance leads to diabetes, diabetes drives heart disease, and heart disease is the leading cause of death in women. In a 2015 Australian study, about one in eight women with PMOS had type 2 diabetes by their mid thirties, against about one in twenty six, and about three times the hospital admissions for high blood pressure and heart disease. In a 2026 Nordic study, women with PMOS at a healthy weight and without diabetes still had about a quarter more heart attacks, strokes, heart failure and cardiovascular deaths combined.
In a 2025 Korean study, depression came about 24% more often and bipolar disorder about 50% more, and the excess was in the women who weren't obese. Pooled in 2017, depression tracked insulin resistance, not testosterone. If you're thinking about hurting yourself, in the US you can call or text 988, any time.
No ovulation, no progesterone
After ovulation, the empty follicle becomes the corpus luteum, which makes progesterone. No ovulation, no progesterone. Her estradiol keeps telling the uterine lining to grow and nothing tells it to stop, so it thickens and sheds in pieces on no schedule: the heavy, unpredictable bleeding. Heavy bleeding drains iron, so I want ferritin at least 75. PMOS carries about four times the odds of endometrial cancer. In a three year trial in women past menopause on Premarin, 74 of 119 had an abnormal lining biopsy on Premarin alone, against 6 of 120 with micronized progesterone twelve days a month. I give progesterone every day.
The gauntlet: one mallet per symptom
The pill gives a withdrawal bleed, not a cycle. Its ethinyl estradiol raises SHBG, so free testosterone drops and skin often clears, but SHBG was the lab telling you about her insulin. In lean women with PCOS on a low dose pill for twelve weeks, SHBG more than doubled while insulin sensitivity got about 15% worse. For contraception, I look at a copper IUD first.
I prescribe spironolactone often for acne and unwanted hair, but it doesn't treat PMOS. Metformin barely moves insulin sensitivity in PMOS trials, and I don't use it. A GLP-1 is an adjunct, on top of optimized hormones, never before them. Every mallet is scored by how far testosterone falls, and lowering a woman's testosterone is harmful, PMOS or not.
The hormone trio
The foundation is the insulin and what I call the hormone trio: progesterone, thyroid and testosterone, with food alongside.
Progesterone. Told you're progesterone intolerant? Most women are started on 100 mg, often too little. Give too little of any hormone and the body pulls back its own production, so she can end up with less. In a 1991 trial, 300 mg brought on a bleed in nine of ten women whose periods had stopped, 200 mg was not significantly better than placebo, and 100 mg was never tested. In another small study, peak levels on 300 mg varied about sevenfold between women. I dose by symptoms, every day, never cycled. In my view, there is no unsafe dose. Slynd, pushed online as the fix, is drospirenone, a synthetic progestin approved only to prevent pregnancy, and I couldn't find a single published study of it in women told they're progesterone intolerant.
Thyroid. A low thyroid lowers SHBG just as insulin does. I judge it by free T3, with a floor of 4, and a suppressed TSH on replacement is fine.
Testosterone. Her total is often normal; the free fraction is high because insulin shrank her SHBG. In trials at women's doses, insulin resistance was no worse than in the comparison group, and in a 2014 trial the gains came only in the dose group closest to 250. Most women feel their best above 250.
Food and lifting. Cut the carbohydrates that come in bags and boxes and the ones you drink, prioritize protein, and don't fear fat. In a 2022 trial with matched calories, women with PMOS did better on insulin and testosterone, and lost a little more weight, cutting carbohydrates rather than fat. And lift something heavy.
Questions for your next appointment
Has anyone measured my insulin? I flag anything above 5. My A1c (above 5.2 is a flag), triglycerides (under 50) and HDL (over 60)? My SHBG and free testosterone, and what were they before the pill? My free T3, not just TSH? Am I ovulating, and if not, why am I not on progesterone, at what dose, every day? My testosterone, DHEA-S and, if I bleed heavily, ferritin? And since fathers of women with PMOS were more than twice as likely to have type 2 diabetes (2018), tell the men in your family to get their insulin checked.
Nobody should stop a prescribed medication on their own because of an article, but you have every right to a provider who treats the foundation and not just the symptoms.
The whole argument:
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⚠️ Educational content, not individual medical advice or a treatment recommendation. Nobody should start, stop or change a prescription because of an article. Your labs and history belong in a one on one.
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